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How to use or fill out ShopRite Vaccine Administration Consent Form
- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'INFORMATION ABOUT VACCINEE' section. Clearly print the name, mailing address, date of birth, gender, city, state, zip code, and telephone number. Ensure all required fields marked with an asterisk (*) are completed.
- Next, provide details about the vaccinee's primary physician including their name, address, and phone number.
- In the 'INSURANCE INFORMATION' section, enter your insurance carrier and ID number as required.
- Proceed to the 'SCREENING FOR INJECTABLE VACCINE ELIGIBILITY' section. For each screening question, select either 'YES' or 'NO' based on your situation.
- Finally, complete the 'CONSENT FOR VACCINATION' section by printing your name and signing where indicated. Make sure to date your signature.
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